Healthcare Provider Details

I. General information

NPI: 1508221615
Provider Name (Legal Business Name): SAMPSON OSAFO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MADISON ST SUITE 404
WORCESTER MA
01608-2058
US

IV. Provider business mailing address

90 MADISON ST STE 404
WORCESTER MA
01608-2073
US

V. Phone/Fax

Practice location:
  • Phone: 508-762-9669
  • Fax: 508-762-9193
Mailing address:
  • Phone: 508-762-9669
  • Fax: 508-762-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number471630935
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: